original New York Times Well article here
Bob Klitzman
Bob KlitzmanCredit Columbia University
My patient, a woman in her 20s with cancer, was doing poorly on chemotherapy. The disease had spread throughout her body. We were doing everything we could to help her, but didn’t know how long she would live – probably only a few months, at most. Her mother came regularly to visit, and sat by her side. Around their necks, they both wore gold crosses on tiny gold chains. Taped on the wall, near the foot of her bed, was a greeting card with a picture of Jesus, in a red cloak with pointy gold beams radiating from his head.
She had long, light brown hair, and her bangs clung to her forehead, sweaty from fever. Initially, her blue eyes looked searchingly up at me with hope, but over time, she more often squinted with anguish. Since the chemo lowered her body’s ability to fight infections, she was confined to her room – a prisoner. I felt bad that we could not offer her any better treatment.
I wondered: Should I call a priest? Should I ask her if she wanted to see one? I wasn’t sure, and didn’t even know how to raise the topic.
I was raised Jewish, and had no idea about when to call a priest, or what doing so might imply. I feared that if I raised the issue, she and her mother would feel that I was giving up on her. So for a few weeks, I did nothing. But every time I visited her, I felt bad.
“Do we ever call a priest?” I finally asked my resident one day in the hall, trying to be casual. I felt uncomfortable asking – as if I should somehow know better. I occasionally noticed priests in white collars and rabbis wearing yarmulkes or black hats riding the elevators and walking the halls, but was surprised to find that other doctors and I simply ignored them, never speaking to them. They operated in an entirely different world.
My resident looked at me as if I were nuts. That is simply not something that we did as physicians. Senior physicians and I never mentioned religion and spirituality on rounds with any patients. In the world of scientific medicine, these topics were taboo. Yet it felt odd to do nothing. I sensed her aloneness and terror in that room – even though she was with her mother – but none of us ever tried to address these feelings in any way.
Religion was never discussed in my medical training. In medical school, a priest maintained a small lounge, providing coffee and tea, where students could sometimes drop in to get coffee, but that was wholly optional, and most students never did so.
Yet studies have documented the importance of religion and spirituality to many patients. Seventy percent of dying patients want their doctor to ask them about their religious beliefs.
Religious beliefs also often affect patients’ wishes when it comes to choosing aggressive end-of-life treatment or palliative care.
However, only half of those patients who want to discuss spiritual or religious concerns with someone in the hospital end up doing so. Those who discuss these issues – whether they initially wanted to do so or not – are, however, more likely to rate their overall hospital care as excellent. Among advanced cancer patients, 88 percent feel religion is at least somewhat important, and 72 percent feel the medical system supported their spiritual needs only minimally or not at all.
Consequently, in 2001, The Joint Commission, which accredits healthcare organizations, decreed that health care providers “receive training on the value of spiritual assessment.” Partly as a result, the number of medical schools with some education on spirituality and health has increased from 13 percent in 1997, to around 90 percent in 2014.
But many medical schools provide only a single lecture on the psychological aspects of end-of-life care, often involving a chaplain who discusses how religion can be important in end-of-life case.
Other barriers exist. In one recent study, half of doctors had received some education in this area, but 62 percent felt their training was inadequate; 73 percent didn’t have enough time to provide spiritual care; and 48 percent felt uncomfortable talking about these topics with patients whose views differed from their own. Still, most medical schools deans do not think more education about spirituality is needed, even if time and resources were available.
Over the years, however, I have increasingly seen how many patients, especially when confronting the end of life, value their emotional, existential and spiritual feelings over further medical treatment when it begins to seem futile.
Eventually, my patient dying from cancer did speak with a chaplain. I noticed him visiting her one day as I walked by her door. I again spotted him two days later heading toward her door. The next morning, I thought that she looked calmer, more relieved than I’d seen her in weeks. She still had unremitting fevers and died a few months later, in that room. But the chaplain had helped her, I felt, in a way that I and medical treatment could not.
I still regret my silence with that patient, but have tried to learn from it. Doctors themselves do not have to be spiritual or religious, but they should recognize that for many patients, these issues are important, especially at life’s end. If doctors don’t want to engage in these conversations, they shouldn’t. Instead, a physician can simply say: “Some patients would like to have a discussion with someone here about spiritual issues; some patients wouldn’t. If you would like to, we can arrange for someone to talk with you.”
Unfortunately, countless patients feel uncomfortable broaching these topics with their doctors. And most physicians still never raise it.
Robert Klitzman, M.D., is a professor of psychiatry and the director of the Bioethics Masters & Online Course and Certificate Programs at Columbia University, and the author, most recently, of The Ethics Police?: The Struggle to Make Human Research Safe.
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